Fees for dual operator procedures
AXA Health offers a fee schedule for complex microsurgical reconstructive breast procedures where surgeons may elect to operate with a colleague (see table below).
These fees apply whether surgeons operate individually or with a colleague.
We’ll authorise procedures where the lead operator works with either:
- another AXA Health-recognised surgeon, or
- a non-consultant grade assistant, who is not recognised by AXA Health.
This last provision aims to support junior surgeons who need to gain experience in these complex procedures.
Agreement for dual operating
Surgeons who wish to perform dual operating for the procedures listed on this page should accept the Dual Operator Specialist Agreement, accessed below.
To enable us to fund dual operating, we've made changes to the standard specialist contract.
We've highlighted these changes, both to the contract, and to our Billing Principles, in the drop down menu below. You'll also find a draft agreement, and the form you'll need to fill out to accept the agreement here.
Please read below the clauses in the AXA Health Dual Operator Specialist Agreement relating to dual operating:
6. YOUR OBLIGATIONS
...
6.2 In the event that You appoint a Secondary Specialist for the purpose of providing Treatment to Members in connection with this Agreement, You hereby agree to:
6.2.1 adhere to the Billing Principles;
6.2.2 ensure that a Secondary Specialist has and maintains practising privileges in the relevant facility in the AXA PPP General Network where the Treatment is being carried out by You;
6.2.3 ensure that, at all times, a Secondary Specialist holds medical malpractice insurance to the level required by the respective Medical Regulations, in connection with the services and/or Treatment of the Members;
6.2.4 in accordance with the Billing Principles, notify AXA PPP by reasonable notice of Your intention to appoint a Secondary Specialist and You acknowledge that AXA PPP shall have the right to reject any such appointment;
6.2.5 ensure that a Secondary Specialist acknowledges and adheres to the obligations and practices in Clauses 5.2, 6.1.1, 6.1.4 – 6.1.9 (inclusive).
6.3 In the event that You appoint a Secondary Specialist who is either (i) not a Fee-Approved Specialist, or (ii) is a Non-Consultant Grade, You hereby acknowledge and agree that You shall have sole responsibility and be liable for the performance and conduct of the Secondary Specialist and, in particular, You shall be held liable in the event that AXA PPP determines that the Secondary Specialist, at the time of Treatment provided by You to a Member, did not comply with Clauses 6.2.2, 6.2.3 and 6.2.5.
...
7. FEES, INVOICING AND PAYMENT
...
7.5 For the avoidance of doubt, in the event that You appoint a Secondary Specialist in accordance with Clause 6.3, AXA PPP shall not be liable to pay any fees, costs or expenses directly to that Secondary Specialist in connection with the provision of any Treatment to Members under this Agreement. You shall have sole responsibility for distributing any fees, costs or expenses which are due to the Secondary Specialist.
...
7.10 AXA PPP may at any time dispute the whole or any proportion of an invoice submitted by You where the invoice or portion of the invoice:
...
7.10.5 includes other amounts that You are not entitled to invoice including, but not limited to, the fees of any Secondary Specialists where the appointment of such Specialist is in contravention of Clause 6.2.4, or amounts in excess of what You are entitled to invoice AXA PPP pursuant to the terms of this Agreement.
...
9. INDEMNITY
9.1 To the fullest extent permitted by law, You shall indemnify and keep AXA PPP and its officers, shareholders, agents and employees indemnified in full from and against any loss and all claims, proceedings, actions, damages, costs, expenses and any other liabilities (including legal costs and expenses) which arise or might arise as a result of:
...
9.1.2 the performance or non-performance of any Secondary Specialist You have assumed responsibility for under Clause 6.3;
9.1.3 any claim or complaint made by a Member in relation to Treatment received from You or a Secondary Specialist appointed by You under Clause 6.3;
9.1.4 Your acts, omissions or negligence or wilful misconduct or those of Your Secondary Specialist appointed under Clause 6.3 ;
9.1.5 The cost of any services in connection with Treatment or follow up Treatment received by a Member that was solely required as a result of or in connection with Your negligence or default or that of Your Secondary Specialist appointed under Clause 6.3; and/or
...
10. INDEMNITY INSURANCE
10.1 You shall, (at Your own cost), take out, maintain in full force and effect at all times during the course of this Agreement and observe the terms and conditions of adequate medical defence union indemnity or medical negligence insurance to cover Your liability and the liability of any Non-Consultant Grade in relation to this Agreement with an insurance provider of good standing and repute, authorised to carry on insurance business of the relevant type in the United Kingdom.
10.2 In the event that You appoint a Secondary Specialist who is either not a Fee Approved Specialist or a Non-Consultant Grade, You hereby agree to ensure that the Secondary Specialist has and maintains in full force and effect adequate medical defence union indemnity or medical negligence insurance in accordance with Clause 10.1.
...
11. DATA PROTECTION
11.3 You agree to ensure that a Secondary Specialist who is either not a Fee Approved Specialist or a Non-Consultant Grade in relation to the provision of Treatment provided by You to a Member adheres to the principles of the Data Protection Legislation and shall not do or omit to do anything which causes AXA PPP to breach its obligations under the Data Protection Legislation under or in connection with this Agreement.
...
15. NOTIFICATION REQUIREMENTS
...
15.2 You hereby agree to ensure that, in the event that You appoint a Secondary Specialist for the provision of Treatment by You to Members in connection with this Agreement, You shall immediately notify AXA PPP by telephone or email in the event that you become aware or have a reasonable suspicion that the events set out in Clauses 15.1.2 – 15.1.7 apply or may apply.
...
New definition added to contract
Secondary Specialist means a Specialist appointed by You to assist in the supply of Treatment services to Members carried out by You
Please read below the relevant clauses in our Billing Principles relating to dual operating.
2.1 - Coding
...
2.8 – Provider Code
Your Provider Code is your unique identifying code. Your Provider Code should be used solely to bill for treatment that you have carried out yourself for a member. You must not use your Provider Code to invoice for any treatment or services provided by anyone else. The only exception is where AXA Health has approved the appointment of a secondary specialist who has not been recognised by AXA Health to provide additional support in the treatment of a member by you (please see the ‘Multiple Specialist Requests’ section below).
...
Multiple Specialist Requests
...
We will only consider requests for additional specialists who are either: (i) recognised by AXA Health for benefit purposes in connection with the provision of treatment to members; or (ii) if they are not recognised by AXA Health, specialists who are non-consultant grade practitioners working under the supervision of a specialist recognised by AXA Health.
When agreeing treatment we will provide an estimate of fees paid for all specialists in connection with the treatment. If, after treatment, you would like us to adjust our estimate, please send us your operation notes and anaesthetic charts, so we can understand:
- your role and each additional specialist’s role in the procedure
- the time spent in theatre and
- the complexities faced.
We will then confirm the fee we will pay you for the treatment. We will not pay you for the fees, costs or expenses of any additional specialist where they are recognised by AXA Health. Additional specialists who are recognised by AXA Health should bill us separately under their own Provider Code. If you appoint an additional specialist who is not recognised by AXA Health, we will pay you directly for all fees in connection with the treatment of a member and it is your responsibility to direct the relevant fees to each additional specialist.
We will not pay you for the fees, costs or expenses of any additional specialist where you have not submitted a request to us for approval of the additional specialist.
...
Ethical Guidance For Bespoke Requests
We expect you to follow the ethical guidance provided by your regulatory body. An example of such guidance from the GMC can be found here: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/duties-of-a-doctor. We also expect any additional specialists you appoint to follow the ethical guidance in connection with treatment provided by you.
Please click on the button below to download a draft copy of the AXA Health Dual Operator Specialist Agreement, enabling dual operating.
Please click on the button below to fill out a short form and accept the AXA Health Dual Operator Specialist Agreement.
Fees for complex microsurgery
| Procedure code | Procedure Narrative | Fee |
| B2986 |
Reconstruction of breast using deep inferior epigastric perforator flap (DIEP) |
£5,500 |
| B2996 |
Reconstruction of breast using deep inferior epigastric perforator flap (DIEP) |
£7,000 |
| B2999 |
Reconstruction of breast using stacked deep inferior epigastric perforator flap (DIEP) |
£5,500 |
| B3810 |
Reconstruction of breast using SGAP (superior gluteal artery perforator) flap |
£5,500 |
| B2987 |
Reconstruction of breast using transverse upper gracilis (TUG) flap |
£5,500 |
Reimbursement examples
| Authorised? | Surgeon combination | Seniority | AXA Health recognition status | Reimbursement |
| Yes | Single operator | Consultant level | Recognised by AXA Health | Surgeon invoices AXA Health for full amount of published fee |
| Yes | Dual operators | Both surgeons at consultant level | Both surgeons recognised by AXA Health | Each surgeon invoices AXA Health directly for half the published fee |
| Yes | Dual operators | Consultant level lead surgeon operates with non-consultant grade assistant |
Lead surgeon recognised by AXA Health |
Lead surgeon invoices AXA Health for full amount of published fee & reimburses assistant as appropriate |
| No | Dual operators | Both surgeons at consultant level | Only lead surgeon recognised by AXA Health | For legal and indemnity reasons, we cannot fund a procedure carried out by a consultant level surgeon not recognised by AXA Health |
Acellular Dermal Matrix use in Breast Surgery
- AXA Health strives to ensure that our members receive safe and effective care and that they are are fully supported in making decisions regarding treatment they receive.
- We rely on the expertise and dedication of clinicians like you to help us achieve this ambition.
- We have become aware that some AXA Health members have faced significant shortfalls because of the additional costs of expensive biological Acellular Dermal Matrix (ADM) implants.
- We appreciate that use of implants is a clinical decision which will have factored in the paucity of high-quality research and possible alternatives. We advocate that our members undergo a robust consenting process when the use of ADM is an option, as it is imperative that they not only are fully aware of the risks, benefits, long and short term, but also of the potential financial burden which may arise.
- We expect specialists are routinely following the recommendations made by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), Acellular Dermal Matrix (ADM) Products Used in Implant-Based Breast Reconstruction Differ in Complication Rates: FDA Safety Communication | BAPRAS
- Further, that you are supporting shared decision making as outlined in the joint clinical guidelines published by the same bodies, Oncoplastic breast surgery: A guide to good practice (associationofbreastsurgery.org.uk).
- Given that one of the recommendations is for all ADM to be included in the Breast and Cancer Implant Registry (BICR) please be aware that we may, from time to time, perform audit with reference to this data.
- Following the recommendations of the Cumberlege Inquiry you can appreciate our desire to seek assurance that patients are receiving safe and effective care and that they are fully consented for both clinical and financial risks associated with these procedures and outcomes monitored.
For queries on these provisions, please email the Specialist Relations team on the button below.